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Posts from the ‘Joy Jacobson’ Category

Workplace Violence Against Nurses: We Are Not Made of Steel

Reni M. Papananias, RN

Reni M. Papananias, RN

This guest post is by Reni M. Papananias, RN, a nurse, photographer, and writer. She’s pursuing her master’s degree in adult and geriatric primary care with a focus on HIV and palliative care at the Hunter-Bellevue School of Nursing in New York City, where she was a student last fall in CHMP senior fellow Joy Jacobson’s narrative writing class for graduate nursing students. Papananias is at work on a memoir about loss and lives in Brooklyn. Names have been changed in this post to protect anonymity.

Nursing is a hard job. It comes with seemingly endless expectations of selflessness, and I have always prided myself on the fact that no matter how tough things get, I don’t cry. I step into my armor and keep the drama at bay—or, rather, that’s what I used to do, until an attack by a patient’s family member left me sobbing under the nurse’s station.

We were waiting for a trauma case to finish in the OR. Minutes before the patient rolled out, a short, stout woman wearing thigh-high boots stormed into the unit and demanded to know where her boyfriend was. She was in a complete rage. “Where’s Dempsey?!” she shouted, eying the unit like a hawk looking for blood.

I approached her and reassured her that Dempsey was not in the recovery room yet, but that everything was okay. I made every effort to be kind and informative. She remained aggressive and accused us of lying to her. Her voice and mood escalated until the doors from the OR swung open and Dempsey arrived safely into the recovery bay.

Things after his arrival were routine: IV fluids and pain meds were administered. I was in charge that evening and I asked the nurse, as I always do, if he needed any help; he insisted that he had it covered. As I turned to walk away, Dempsey’s girlfriend called something out at me. I didn’t hear what she said, so I kept walking. Then she said it again. This time I heard, loud and clear.

I responded, genuinely confused: “Excuse me, are you talking to me?”

“Yeah! I’m talking to you, you *&$% [insert homophobic slur].” My heart started pounding and the tiny hairs on the back of my neck lined up like spurs. I was shaking but managed to choke out the words, “I’m calling security.”

She continued to curse me. Then she threatened my life. “I’ll kill you, you disgusting *&$%.”

That’s when I screamed for help. My co-workers were frozen. They too were in shock. Were they immune to such common acts of workplace violence, the daily subtle yet cutting verbal attacks that nurses face while on duty? That’s when I broke. Tears streamed down my face, I fell to my knees and hid under the desk while she stomped around the unit looking for me.

The rest of the story is a chain of rather discouraging events. Security eventually came but didn’t do much, aside from assess the situation and wait for Dempsey to leave. I overheard someone tell my boss on the phone that my reaction was “emotional.” I was furious. In the days after the event, I was assured that steps were being taken so that this woman wouldn’t be allowed in the hospital again.

These efforts were made in vain, though: seven months later, on another Friday night, Dempsey showed up seeking treatment for a postoperative infection. Dempsey and his girlfriend were transferred to another unit at my manager’s insistence, and while I appreciated this, I found it humiliating that I had to be quarantined for my safety.

They never should have been allowed back on the premises—or at the very least, I should have been informed prior to their arrival. Initially, my manager had asked me if I wanted to press charges, but subtly discouraged me from doing so, suggesting that it might be “a lot to handle” between work and school. No one fully explained my rights or offered supportive services.

This sort of thing happens to nurses more than other health care workers. The Department of Justice reported that nurses are 57% more likely to be assaulted than doctors and that up to 70% of assaults go unreported. There are plenty of reasons for this, including fear of losing one’s job and the normalization of violence against nurses.

Reporting of violent acts against nurses is historically low, despite their high prevalence. Often nurses fear retaliation from hospital administration, lack the knowledge or support from administration due to vague reporting policies, and in turn normalize the behavior, expecting that violence is “just part of the job.” Speaking up may be seen as a sign of weakness or incompetence. Hospital administrators may also be concerned that reporting violent acts may risk patient satisfaction scores and the bottom line.

There remains a need for more research, more workplace violence prevention training for health care workers, and greater public awareness that violence against a nurse is a punishable crime.

I decided that a grassroots approach fit my style. I made it my policy as head nurse to empower my coworkers to become advocates of their own safety. I’m helping them identify escalating behavior and encouraging them to ask for help if they feel threatened.

There are many online guidelines and resources available for nurses and other health care workers. The Emergency Nurses Association has a Workplace Violence Toolkit, and the Occupational Safety and Health Administration just updated its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. And the National Institutes for Occupational Safety and Health offers a free online course, Workplace Violence Prevention for Nurses.

Nurses are not made of steel, and we DO exist. In fact, perpetuating the idea that there’s no place for emotion in health care is a form of self-inflicted violence. Until nurses stop acting like blank-faced, tiny toy soldiers, our lives will continue to be at risk every time we step into our venerable baby blue scrubs and show up for work.

Cure Violence: A Scientific Approach, Not a Moral One

Joy Jacobson is a CHMP senior fellow. Follow her on Twitter: @joyjaco

Over the years that I’ve been writing about health care through a nursing lens, I am always impressed, if not outright astounded, by the work being done to further public health. This month, the American Journal of Nursing has published my latest article, “A Cure for Gun Violence,” on a successful epidemiologic model for curbing urban violence.

In 2013 Gary Slutkin, the founder of Cure Violence, gave a TEDMED talk in which he describes how “clustering” works in the spread of disease—and of violence, especially shootings: “The greatest predictor of a case of violence is a preceding case of violence,” he said. In other words, a shooting can have the same effect on a community as any contagion, spreading by close personal contact.

Cure Violence works to interrupt retaliatory violence by training community members to intervene on violent situations, especially in the aftermath of a shooting. This process is powerfully depicted in The Interrupters, an award-wining documentary. After disrupting transmission, the work shifts focus to educating communities, with a goal of establishing new norms for interacting and resolving conflict.

Cure Violence has reduced the number of shootings and deaths from 41% to 73% in the seven Chicago neighborhoods where it was used. Other cities have shown similar successes.

For my AJN report I talked with nurses and others working with Aim4Peace, a Cure Violence affiliate in Kansas City, Missouri. That program’s director, Tracie McClendon-Cole, told me that although some may scoff at the idea of preventing and treating community violence as a contagious disease, they appreciate it when it’s explained to them. She said:

We look at violence disease-colonies the same way we look at cholera disease-colonies. It’s a scientific approach, not a moral one. We’re looking at the brain and behavior and how the disease of violence is transmitted, how it affects group function.

A study published this month in Pediatrics demonstrates the need for this kind of approach. Young people seen in an urban ER for assault-related injuries showed a much higher risk of becoming involved in subsequent violence. Carter and colleagues followed two groups for two years. All were young drug users: one group was seen in the ER for assault-related injuries and the other was not. The researchers found that 59% of the young people treated for assault were involved in firearm violence in some way in the following two-year period, almost all of them as victims—threatened, injured, or killed by guns. Nearly a third were aggressors, as well.

Preventing retaliatory violence is where hospitals can intervene, to profound effect. One recent study (abstract here) showed hospital violence-intervention programs to be effective in reducing rates of injury and reinjury, as well as costs. Those researchers recommend that such programs be implemented in all trauma centers. I’ve gathered some resources for health care providers and others who may want to look into starting such a program.

The National Network of Hospital-based Violence Intervention Programs consists of more than two dozen programs working “to stop the revolving door of violent injury in our hospitals.” The Web site features support materials for starting a hospital program.

Violence Is Preventable: A Best Practices Guide for Launching and Sustaining a Hospital-based Program to Break the Cycle of Violence, produced by Youth ALIVE!, encourages nurses and other clinicians to expand their patient advocacy to encompass policy advocacy.

Preventing Youth Violence: Opportunities for Action.
This 2014 report from the Centers for Disease Control and Prevention proposes that violence against children, teens, and young adults isn’t inevitable and recommends a strategy of collaboration among educators, public health professionals, religious organizations, law enforcement, and business owners.

Contagion of Violence: Workshop Summary. A 2012 Institute of Medicine Forum on Global Violence Prevention convened a workshop to explore the “epidemiology” of violence, including modes of transmission and strategies for interruption. The book is available for free download.

And check out this Cure Violence video that explains the model and shows Aim4Peace community workers in action.

The Last Thousand Words

clip_image002This guest post is written by Rusty Greene, RN, a student in the doctor of nursing practice program at the Hunter–Bellevue School of Nursing in New York City. He was a student last spring in CHMP senior fellow Joy Jacobson’s narrative writing class for graduate nursing students. Names have been changed in this post to protect anonymity.

Two years ago, I got a tattoo. I never thought it would help someone die.

My right upper arm is covered with a sketch of a seahorse. My uncle and my grandfather have the same tattoo. Both of them were in the navy. They got the tattoo because the seahorse symbolized strength and determination.

I got mine for different reasons. When I was at an aquarium several years ago, I saw the seahorses. They are strange creatures indeed. The males give birth and they are coated in a crusty layer of bone. The wings on their backs flicker like tiny prehistoric appendages. After the fathers give birth, they care for a brood of over 1,000, knowing that more than 950 of them won’t survive.

Seahorses are rugged and resilient. But they also bend the rules of gender. They turn the concept of caring on its head. The concept of “nursing” is not particular to the female of the species.

This is something I understand because I’m a male nurse.

In nursing school, I took many courses on compassion, the empathic response, and palliative care. While I believe anyone is capable of mastering these skills, the tone of these subjects often takes a female perspective. This is particularly true when discussing burnout and fatigue. In fact, the concept of compassion fatigue has been bandied about over the past few years as a very real and uncomfortable condition for nurses and caregivers in general. It is often discussed in the context of having a healthy work/life balance, where a nurse must juggle the demands of caring for strangers only to go home and tend to children, a husband. and a mortgage.

Additionally, when discussing care of the dying, medical literature sometimes goes to the other extreme, providing a sometimes cold and cookie-cutter set of guidelines to help patients “pass.” An Internet search will give you several examples. To combat the sterile nature of these reports, some will say that it is okay to cry with your patients and hold their hand when they are dying. I had a professor in nursing school who said she even climbed into bed with a patient and held her as she died of breast cancer. To me, that seems like a bit too much.

So the messages are mixed. Have compassion but don’t deplete yourself. Follow best practices but tailor them to your own nursing style. Have a big heart but be a man. More often than not, these messages remain muddled. But sometimes, circumstances can create the perfect moment of clarity.

It was Saturday night and Alex was dying of AIDS.

I remember walking in to bathe him near the end of my shift. I entered his room with a basin full of warm water and some liquid soap. As is almost always the case with those who are dying, the room was preternaturally still, as if the air was waiting for the event common to us all but rare in its profundity. Alex was moving on, expiring, “going to the next life.” All of us only get to do it once and it is a singular experience. The atmosphere seems to know this.

I pulled back Alex’s sheets to reveal his frail and failing body. From feet to neck, he was covered in tattoos. They were intricate, colorful designs that swirled on his flesh, dancing this way and that. Then I looked into Alex’s eyes and I saw terror. His “moving on” wasn’t going to be easy. And I had to find a way to comfort him.

I showed him my tattoo and explained its significance. He smiled as best he could and said, “Nice.”

As I was washing his leg, I tentatively asked him about a palm tree and some goldfish drawn on his knee. He explained as best he could about getting that particular tattoo in Florida when he was on vacation with an ex-girlfriend. And at that moment, I saw something soften in his eyes. He went on to describe several more images on his body. A series of stars drawn in Amsterdam on his right shoulder. A black butterfly on his left pectoral muscle that he called “Dark Hope.” The more he shared, the more he relaxed. “Have a good night,” I said softly when I was finished.

“You too,” he said.

Alex died the next day.

Somewhere in between the lectures, the textbooks and the life experience, a space for healing was created. There were no tears. There were no hugs. It was just two guys talking about their tattoos. But it was deeply emotional. I didn’t feel exhausted or distraught or less of a man for caring very deeply about my patient. And Alex finally got some rest.

They say a picture is worth a thousand words. That night they were worth far more than that.

The Power of Words, and of Silence

Black-capped chickadee.  Matt MacGillivray, flickr

Black-capped chickadee.
Matt MacGillivray, flickr

Joy Jacobson is a CHMP senior fellow. Follow her on Twitter: @joyjaco

For the past couple of years I’ve attended The Power of Words, the annual conference of the Transformative Language Arts Network. I’ve become more of a conference-goer in recent years, as well as a presenter, but this one seemed unlike any of the others I’ve attended. Novelists and poets, musicians and composers, expressive-arts therapists and health care workers, those new to writing and those who’ve devoted their lifetimes to the craft all gathered for a few days of “workshops, performances, talking circles, celebration and more.” 

I left last year’s gathering, held at the beautiful grounds at Pendle Hill, a Quaker retreat outside Philadelphia, with the phrase radical acceptance going through my mind. I won’t be able to attend this year’s conference, to be held at Lake Doniphan Retreat Center in Kansas City, MO. I’ll miss those people and the community that gets made when like minds and intentions come together.

It’s an aptly named conference. Last year I led a poetry workshop on “self-elegy,” and it was indeed powerful to see what a group of readers and writers could compose in 90 minutes. (Two brilliant attendees, Seema Reza and Maiga Milbourne, each blogged about it, here and here.) But that phrase, power of words, has got me thinking, too, about the powers of silence.

For the first time in the many years that I’ve owned a cell phone (or has it owned me?) I have turned off the text-message-notification noise. For 10 days now there has been no beep, no trill, no hum or vibration, no ring-a-ding-ding when a message arrives. It started one insomniac night as an attempt to block out any potential disruption to sleep, should I have been lucky enough to fall back into it. In the morning I thought it might be nice to take a vacation from the fake bell—not from text messaging itself, just from the relentlessly Pavlovian audio.

As I write I’m sitting outside. There’s a distant thrum whose source I can’t quite identify, probably a train. A couple of chickadees perform their unrepeatable tweets. The 10 AM church bell chimes, and my little dog decides to yap in response to something beyond my hearing. Clank: a truck hits a bump. A neighbor’s air conditioner rolls over and over. The cicadas start, then drop, then start again their annual threnody to summer.

In attending to these entirely ordinary sounds I realize something about awareness. Perhaps what I found so remarkable about the Power of Words conference didn’t have entirely to do with the words themselves, whether written, read aloud, spoken, sung, or chanted (and they were remarkable). It had to do, as well, with the attention we all paid to one another: undistracted, unrushed, clear-eyed and -eared—radical—attention.

I just checked my phone. In the time it took me to write the previous paragraph a friend texted. Perhaps we could have a bike ride or a walk later today? I’ll get back to him in a minute or two.

Narratives of Diversity: Encouraging Cultural Responsiveness

By Jim Stubenrauch

What’s especially exciting about writing with a group of people in a workshop setting is the opportunity it affords to witness others giving their stories form and bringing them into the open, in real time. Sometimes, it’s astonishing what people can produce in just a few minutes.

I recently teamed up with two colleagues, nurse practitioner and nursing educator Dr. Kenya Beard and poet and writing teacher Joy Jacobson, to present Narratives of Diversity: Encouraging Cultural Responsiveness, a daylong workshop held at the CUNY Graduate Center. The goal of the day was to achieve a better understanding of how students, patients, and professional colleagues experience themselves and others in increasingly diverse health care and educational environments. Participants explored their own experiences of diversity and marginalization through guided creative writing exercises and discussion and, together, we sought strategies that all of us could use to become more culturally responsive, both personally and in our professional roles. (To learn more about Kenya’s work in promoting multicultural education and reducing health disparities, see Joy’s interview with her, here.)

Shannon Richards-Slaughter, left, with her mother, Rose Richards, ca. 1987

Shannon Richards-Slaughter, left, with her mother, Rose Richards, in 1987

One of the workshop participants, Shannon Richards-Slaughter, an educator and writer from Charleston, South Carolina, wrote a first draft of the following piece during a 20-minute guided writing session and then shared it with the group. The prompt was: “Write about a time when you felt marginalized or witnessed someone else being marginalized.” Shannon’s story isn’t primarily about something that occurred in an institutional or professional setting; rather, she used the idea of marginalization to examine her increasingly tenuous connection to her mother, who is slowly withdrawing from her relationships with friends and family. Anyone who has provided long-term care for an aging loved one will recognize the complex, sometimes conflicting emotions Shannon expresses in this poignant and heartfelt piece. Our great thanks goes to Shannon for sharing this with HealthCetera‘s readers.

Heart on Automatic

We have marginalized my mother. Or has she marginalized us? She’s 96 and stays all day in her bedroom, our former guest bedroom. That’s how she acts. Like a guest. Like someone just passing through. Physically, she’s fine, her doctors say: blood pressure, pulse, and—now, with the pacemaker—heart. All fine. She takes less medicine than my husband and I do. But she is far away, and in some ways, we have let her go. At first, I took her to all the specialists—the gerontologist, the neurologist, the psychologist, the psychiatrist. There were work-ups and tests and consultations:

She might be depressed.

No, it’s not Alzheimer’s.

It could be an eating disorder associated with the elderly.

No, it’s atrophy of the capillaries of the brain.

It’s not dementia. We can’t say it’s dementia.

Maybe, it’s a form of dementia…

She’s traveled so far away from her family, her friends, to live with us. She’s obsessed with finding out where she is, sometimes asking me, “What happened to the house?” Meaning the house she’s lived in for over fifty years, 1004 North Michigan Avenue in Atlantic City.

“What happened to the house?”

As if the house has disappeared because she can’t see it. As if it doesn’t exist because she’s not in it. It’s still there, we tell her. You’re just staying with us now. We beg her to come, sit with us around the kitchen table, have dinner with us. Please. Don’t sit over there on the sofa by yourself. Join us, be with us.

“I’m ruining your life,” she says. “I’m making trouble.”

And she is and she does when she refuses to take her medicine, to get dressed, to eat anywhere but in her bedroom, to talk to her sisters long-distance on the phone. She is so unhappy and so angry. We take her back then, to 1004 North Michigan Avenue, because maybe, just maybe, if she is in her own home, back among her own surroundings, siblings, friends, maybe then she’ll do better. But she is unhappy and angry and won’t eat and doesn’t like the lady who comes in to help her.

We bring her back. This time to Ashley River Plantation, an assisted living facility which is supposed to give her independence and dignity and where she stays in her room all day and asks, “What is this place again? Am I on assistance?”

Finally, it’s back at our house when she asks, “Where am I now?”

“Charleston,” I say.

“But where in Charleston?”

“My house.”

She turns away. Swimming out to some other shore. And we have let her go. I have let her go.

I take her meals up to the room and tell her what’s on the plate. I turn on the lights so she won’t be always in the dark. Every now and then I take her to the beauty parlor and the podiatrist.

She will not go to church.

I take her to the doctor where they tell us the same things:

Get her to eat.

Make sure she takes her meds.

Keep her active.

But we’ve heard it all before, and my heart is on automatic, a remorseless machine pumping energy into my care of her. I feel the line attaching us grow increasingly slack. She is beyond my reach.

Rose Richards in 2003

Rose Richards in 2003

Shannon Richards-Slaughter is a faculty member in the Writing Center/Center for Academic Excellence at the Medical University of South Carolina. She regularly meets with health professions students from all six of the university’s colleges to review a variety of writing assignments, including literature reviews, research papers, papers for publication, capstone projects, dissertations, scientific papers, and grant proposals. Nursing students make up the majority of her Writing Center appointments. In another life, she has been a playwright and a fiction writer, most notably winning the New Professional Theatre 2005 Writer’s Festival Award and the Ms. Magazine College Fiction contest.

Jim Stubenrauch is a senior fellow at the Center for Health, Media & Policy and teaches writing at the Hunter-Bellevue School of Nursing.


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